In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection.

OBJECTIVE: In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD). METHODS: We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed. RESULTS: A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10). CONCLUSIONS: The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.

Treatment of an Infected, Bovine Pericardial Carotid Patch: Excision and Reconstruction with a Superficial Femoral Arterial Interposition Graft.

Carotid patch infection is a rare complication but one often associated with severe morbidity, including hemorrhage, stroke, cranial nerve injury, and mortality. We present a case of a gram-negative bacterial infection of a bovine pericardial carotid patch. Treatment ultimately required patch explantation and reconstruction with a femoral arterial interposition graft.

Clinically Important Misclassification of Aortic Valve Stenosis Severity Using Non-Invasive Techniques: Simultaneous Echocardiography and Cardiac Catheterization During Transcatheter Aortic Valve Implantation in Awake Patients.

BACKGROUND: Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified. METHODS AND RESULTS: TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001). CONCLUSION: Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.

Genetic Variants in LRP1 and ULK4 Are Associated with Acute Aortic Dissections.

Acute aortic dissections are a preventable cause of sudden death if individuals at risk are identified and surgically repaired in a non-emergency setting. Although mutations in single genes can be used to identify at-risk individuals, the majority of dissection case subjects do not have evidence of a single gene disorder, but rather have the other major risk factor for dissections, hypertension. Initial genome-wide association studies (GWASs) identified SNPs at the FBN1 locus associated with both thoracic aortic aneurysms and dissections. Here, we used the Illumina HumanExome array to genotype 753 individuals of European descent presenting specifically with non-familial, sporadic thoracic aortic dissection (STAD) and compared them to the genotypes of 2,259 control subjects from the Atherosclerosis Risk in Communities (ARIC) study matched for age, gender, and, for the majority of cases, hypertension. SNPs in FBN1, LRP1, and ULK4 were identified to be significantly associated with STAD, and these results were replicated in two independent cohorts. Combining the data from all cohorts confirmed an inverse association between LRP1 rs11172113 and STAD (p = 2.74 × 10(-8); OR = 0.82, 95% CI = 0.76-0.89) and a direct association between ULK4 rs2272007 and STAD (p = 1.15 × 10(-9); OR = 1.35, 95% CI = 1.23-1.49). Genomic copy-number variation analysis independently confirmed that ULK4 deletions were significantly associated with development of thoracic aortic disease. These results indicate that genetic variations in LRP1 and ULK4 contribute to risk for presenting with an acute aortic dissection.

The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Recent studies demonstrate that uncomplicated acute type B aortic dissection (uATBAD) patients with enlarged descending thoracic aortic diameters are at high risk for development of complications. This study aimed to determine the association of maximum ascending aortic diameter and area and outcomes in patients with uATBAD. METHODS: All patients admitted with uATBAD from June 2000 to January 2015 were reviewed, and those with available imaging were included. All measurements were obtained by a specialized cardiovascular radiologist, including the maximum ascending aortic diameter and area. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analyses using SAS 9.4 software (SAS Institute, Cary, NC). RESULTS: During the study period, 298 patients with uATBAD were admitted, with 238 having available computed tomography and 131 having computed tomography angiography imaging and adequate follow-up available for analysis. The cohort had an average age of 60.96 ± 13.4 years (60% male, 53% white). Ascending aortic area >12.1 cm2 and ascending aortic diameter >40.8 mm were associated with subsequent arch and proximal progression necessitating open ascending aortic repair (P < .027 and P < .033, respectively). Ascending diameter >40.8 mm predicted lower intervention-free survival (P = .01). However, it failed to predict overall survival (P = .12). Ascending aortic area >12.1 cm2 predicted lower intervention-free survival (P = .005). However, this was not predictive of mortality (P = .08). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for mortality (P < .001). Neither maximum ascending aortic diameter >40.8 mm (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.42-2.83; P = .85) nor area >12.1 cm2 (HR, 0.992; 95% CI, 0.38-2.61; P = .99) significantly predicted mortality when controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 7.34; 95% CI, 2.3-23.41; P < .001), diabetes mellitus (HR, 6.4; 95% CI, 2.17-18.93; P < .001), age (HR, 1.06/y; 95% CI, 1.03-1.10; P < .001), history of stroke (HR, 5.03; 95% CI, 1.52-16.63; P = .008), and syncope on admission (HR, 21.11; 95% CI, 2.3-193.84; P = .007). Ascending aortic diameter >40.8 mm (HR, 2.01; 95% CI, 1.03-3.95; P = .04) and maximum ascending aortic area >12.1 cm2 (HR, 1.988; 95% CI, 1.02-3.87; P = .04) on admission persisted as predictors of decreased intervention-free survival after controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 3.142; 95% CI, 1.47-6.83; P < .004), syncope on admission (HR, 26.3; 95% CI, 2.81-246; P < .004), and pleural effusion on admission (HR, 3.02; 95% CI, 1.58-5.77; P < .001). CONCLUSIONS: uATBAD patients with ascending aortic area >12.1 cm2 or maximum ascending aortic diameter >40.8 mm are at high risk for development of subsequent arch and proximal progression and may require closer follow-up or earlier intervention. Ascending aortic size (diameter and area) is predictive of decreased intervention-free survival in patients with uATBAD.

Imaging characteristics of acute type A aortic dissection and candidacy for repair with ascending aortic endografts.

BACKGROUND: Acute type A aortic dissection (ATAD) remains associated with substantial short-term mortality, and despite increasing rates of surgical repair, as many as 10% to 20% of patients do not undergo surgery because of comorbidities and dissection-related complications. For patients unable to undergo open repair, previous attempts at endovascular treatment of ATAD used devices originally designed for deployment in the descending thoracic aorta. Industry has begun to support early investigational devices meant specifically for placement within the ascending aorta. We evaluated relevant aortic parameters to examine which patients may be candidates for repair with an ascending aortic endograft. METHODS: We reviewed 100 consecutive patients in our institutional ATAD database with contrast-enhanced computed tomography imaging on an Aquarius iNtuition workstation (TeraRecon, San Mateo, Calif), using curved planar reformatting (vessel tracking) and orthogonal views for measurements. We compared relevant aortic measurements against proposed criteria for future ascending endografts, including various landing zone diameters and intimal tear distances from the distal coronary ostium. RESULTS: Of the 100 patients examined, 39% had proximal intimal tears located outside the tubular ascending aorta. In all, 30% were excluded on the basis of either the presence of a prosthetic aortic valve or significant aortic insufficiency, and 6% were excluded on the basis of the presence of patent coronary artery bypass grafts from the ascending aorta. Many patients had multiple exclusion criteria, and based on various proposed criteria, overall candidacy ranged from 2% to 23%. If a maximum landing zone diameter of 42 mm and intimal tears as little as 20 mm distal to the distalmost coronary were considered treatable, only 8% of patients would have been candidates compared with 20% candidacy if aortic diameters up to 46 mm and intimal tears as little as 10 mm distal to the distalmost coronary were considered treatable. The most frequent single cause for exclusion was inadequacy of the proximal landing zone. Iliofemoral vascular access was also assessed and deemed adequate in >90% of cases. CONCLUSIONS: A minority of patients suffering ATAD would currently qualify for ascending aortic endografting on the basis of anatomic criteria alone. Future device designs should take into account these common anatomic exclusion criteria so that more versatile devices may be developed and commercially available to treat a larger number of patients.

Superficial Femoral Artery Occlusion Reduces Aortofemoral Bypass Graft Patency.

OBJECTIVES: The effect of superficial femoral artery (SFA) occlusion on long-term patency of aortofemoral bypasses (AFBs) for aortoiliac occlusive disease (AIOD) was examined. METHODS: The AIOD database was reviewed to identify risk factors for AFB failure. The status of the SFA at AFB procedure was categorised as patent; diseased treated (DT), if the SFA occlusion was intervened on concomitant to AFB; or diseased untreated (DU), if the SFA was occluded but not revascularised. Censoring hierarchies for primary patency and patent graft survival time were constructed. Data were analysed by contingency table, Kaplan-Meier, and Cox regression analysis. RESULTS: Between 2004 and 2015, 122 AFB (9 unifemoral, 113 bifemoral) for AIOD were performed. Seventy-five (61%) were female and the mean age was 60 ± 10 years. At the time of AFB, 50 (41%) had occluded SFAs (DT/DU). Of these, 15 had concomitant SFA revascularisation (i.e., DT) at the time of AFB. Patients with occluded SFAs had greater history of prior aortoiliac/infrainguinal procedures (aortoiliac 54% vs. 22%, infrainguinal 58% vs. 25%, both p < 0.001), Trans-Atlantic Inter-Society Consensus II classification of femoropopliteal type D lesions (78 vs. 10%, p < 0.001), Rutherford 4-6 categories (80% vs. 57%, p = 0.011), and longer hospital stay (median 11 vs. 7 days, p < 0.004). SFA status did not affect 30 day mortality (overall 9%); however, sub-analysis showed DT had significantly higher mortality than DU (p < 0.03). Over a median follow up of 7.7 (IQR 4.3-11.4) years, primary patency at one and five years was 98.3% and 91.2% in patients with patent SFAs, 87.9% and 82.7% in DU, and 72.7% and 43.6% in DT (p < 0.001), respectively. On multivariable analysis, low baseline glomerular filtration rate (HR 1.01, p = 0.022), DT (HR 3.7, p = 0.020), Rutherford 4-6 (HR 9.1, p = 0.048), and occluded SFA (HR 3.9, p = 0.009) adversely affected primary patency of AFBs. Long-term mortality was not different between the SFA status groups (p = 0.279). CONCLUSION: Baseline SFA occlusion predicted a fourfold increased hazard of primary AFB failure. Concomitant SFA revascularisation did not improve AFB durability and was associated with increased in hospital mortality.

Determinants and outcomes of nonoperative management for blunt traumatic aortic injuries.

OBJECTIVE: The natural history and parameters for successful nonoperative management of blunt traumatic aortic injuries (BTAIs) involving the descending aorta are poorly understood. We examined our experience with nonoperative BTAI treatment (anti-impulse, blood pressure) and evaluated for determinants of successful outcomes. METHODS: We performed a review of our institutional prospective trauma registry database for all BTAI patients from 1999 to 2015. Computed tomography angiography was used to classify aortic injuries on the basis of severity: grade I, intimal tear; grade II, intramural hematoma; grade III, aortic pseudoaneurysm; and grade IV, free rupture. Grade IV injuries were excluded from nonoperative management. Baseline characteristics, clinical outcomes, and follow-up lesion resolution were compared within the medically managed cohort and between surgical and nonoperative groups using univariate and multivariable analysis. RESULTS: Among 338 BTAI patients admitted between 1999 and 2015, 67 BTAI patients were managed nonoperatively; 26 (54%) had grade I BTAI, 22 (46%) had grade II, and 2 (4%) had grade III. Both grade III injuries required a late thoracic endovascular aortic repair after initial medical management and were excluded from analysis. In all, 48 were managed with initial medical therapy, and the remaining 19 died on admission or before definitive treatment. Among the 48 medically managed, the median age was 34 years, and 14 (29%) were female. Six of the 48 (12%) were transferred from other facilities. There was no significant difference in baseline characteristics or early outcomes between BTAI grades. Median injury resolution time was 39 days for grade I and 62 days for grade II (P = .03). Compared with a surgical cohort, BTAI grade and Abbreviated Injury Scale score for the chest were the only significant determinants of propensity to operate. CONCLUSIONS: Based on these limited data, it appears that patients with minimal aortic injuries (grades I and II) may be managed medically, with the majority resolving within 8 weeks. Minimal aortic injury is associated with low mortality and excellent intermediate-term outcomes. Further prospective studies are required to validate these findings.

New type A dissection after acute type B aortic dissection.

OBJECTIVE: Aortic dissection is a dynamic process that can progress both proximal and distal to the initial entry tear. We sought to determine associations for development of proximal progression or new type A aortic dissection (NTAD) after acute type B dissection (ATBD) and its effect on survival of the patient. METHODS: We reviewed all cases of acute aortic dissection that we managed from 1999 to 2014. Univariate and bivariate analyses were performed to identify correlates of NTAD. Multivariable regression and proportional hazards regression analysis was done to determine the effect of dissection progression on long-term survival. RESULTS: Among 477 cases of ATBD managed, 19 (4.0%) patients developed NTAD during a median follow-up of 4.1 (interquartile range, 1.4-7.7) years. Median time from diagnosis of ATBD to NTAD was 124 (interquartile range, 23-1201) days. Baseline predictors for development of NTAD at initial ATBD admission included bicuspid aortic valve (P = .006) and age <60 years (P = .012). Although not statistically significant, point estimates indicate that thoracic endovascular aortic repair was twice as frequent in NTAD cases as in non-NTAD cases. Overall 5-year survival was 70.2%. Patients who had repair of NTAD appear to have longer survival, although this effect is on the margin of statistical significance (P = .051). After risk factor and correlates of NTAD adjustment, this effect was no longer apparent (P = .089). CONCLUSIONS: The natural history of ATBD is such that there is a persistent risk of NTAD, with the highest risk in the first 6 months. Factors associated with NTAD include bicuspid aortic valve and young age. Thoracic endovascular aortic repair did not have a large effect on risk. Timely diagnosis and repair of NTAD are associated with good survival rates. Lifelong surveillance is warranted in all cases of descending thoracic aortic dissection regardless of initial treatment modality.

LOX Mutations Predispose to Thoracic Aortic Aneurysms and Dissections.

RATIONALE: Mutations in several genes have been identified that are responsible for 25% of families with familial thoracic aortic aneurysms and dissections. However, the causative gene remains unknown in 75% of families. OBJECTIVES: To identify the causative mutation in families with autosomal dominant inheritance of thoracic aortic aneurysms and dissections. METHODS AND RESULTS: Exome sequencing was used to identify the mutation responsible for a large family with thoracic aortic aneurysms and dissections. A heterozygous rare variant, c.839G>T (p.Ser280Arg), was identified in LOX, encoding a lysyl oxidase, that segregated with disease in the family. Sanger and exome sequencing was used to investigate mutations in LOX in an additional 410 probands from unrelated families. Additional LOX rare variants that segregated with disease in families were identified, including c.125G>A (p.Trp42*), c.604G>T (p.Gly202*), c.743C>T (p.Thr248Ile), c.800A>C (p.Gln267Pro), and c.1044T>A (p.Ser348Arg). The altered amino acids cause haploinsufficiency for LOX or are located at a highly conserved LOX catalytic domain, which is relatively invariant in the population. Expression of the LOX variants p.Ser280Arg and p.Ser348Arg resulted in significantly lower lysyl oxidase activity when compared with the wild-type protein. Individuals with LOX variants had fusiform enlargement of the root and ascending thoracic aorta, leading to ascending aortic dissections. CONCLUSIONS: These data, along with previous studies showing that the deficiency of LOX in mice or inhibition of lysyl oxidases in turkeys and rats causes aortic dissections, support the conclusion that rare genetic variants in LOX predispose to thoracic aortic disease.

Metabolic Syndrome but not Obesity Adversely Affects Outcomes after Open Aortoiliac Bypass Surgery.

BACKGROUND: Although the incident risk of peripheral artery disease increases in patients with metabolic syndrome, several authors report favorable outcomes in obese patients after arterial bypass surgery. We examine the effect of the so-called "obesity paradox" and metabolic syndrome on outcomes after open aortoiliac bypass surgery. METHODS: We identified patients between 2004 and 2015 who had open surgical bypass for aortoiliac occlusive disease. We excluded patients with endovascular repair and those treated primarily for aneurysmal disease. Variables that were analyzed included preoperative medical history, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease II classification, Rutherford classification, intra-operative, and postoperative outcomes. Metabolic syndrome was defined by World Health Organization criteria: diabetes and 2 or more of dyslipidemia, hypertension, and obesity (body mass index > 30 kg/m2). Data were analyzed by stratified Kaplan-Meier and multiple Cox regression for outcomes including long-term mortality and reintervention rate. RESULTS: There were 154 open bypass surgery patients during the study period with a median age of 60 years (interquartile range [IQR] 53-68), median glomerular filtration rate 76.1 mL/min (IQR 54-102), and 58% female prevalence. In all, 53 patients had metabolic syndrome (4%), and 14 patients (9%) were obese but did not have metabolic syndrome. Primary bypass graft patency was 89.0 ± 2.7% at 1 year and 77.4 ± 4.1% at 5 years and was not significantly different between metabolic syndrome, obese, and nonmetabolic syndrome patients. Reintervention rate for the entire cohort was 25.3 ± 3.7% at 1 year and 40.6 ± 4.7% at 5 years. In those with and without metabolic syndrome, reintervention rate at 1 and 5 years was 33.0 ± 6.8% vs. 21.1 ± 4.2% and 56.1 ± 7.9% vs. 30.7 ± 5.4%, respectively (log-rank P = 0.003). In multivariable analyses, metabolic syndrome (hazard ratio [HR] 1.8, P = 0.036) and critical limb ischemia (CLI) (HR: 3.2, P = 0.001) were the only independent predictors of reintervention. Neither obesity nor the individual components comprising metabolic syndrome was a risk for reintervention. Multivariate analysis demonstrated age, female gender, CLI, and nonobesity as the independent risk factors for long-term mortality. CONCLUSIONS: Our study supports the "obesity paradox" that obesity by itself is not a risk factor for reintervention and was a protective factor for mortality after open aortoiliac bypass surgery. Bypass graft patency and major amputation rates were not affected. Although the individual components do not predispose to worse outcome, metabolic syndrome is a constellation of factors that, together, are associated with adverse events.

Indications and Outcomes of Open Inferior Vena Cava Filter Removal.

BACKGROUND: Despite recommendations for retrieval of inferior vena cava (IVC) filters, most are not removed in a timely manner. Longer IVC filter dwell times are associated with caval wall perforation and tilting that make percutaneous retrieval more difficult. Open IVC filter removal is generally reserved for patients with symptoms referable to the filter, such as chronic back and abdominal pain. We present our management algorithm and review of cases of open IVC filter removal. METHODS: Patients referred for management of implanted IVC filters from May 2010 to May 2016 were included. Demographic and imaging were reviewed for cases requiring open surgical removal. RESULTS: There were 221 percutaneous retrieval attempts in 218 patients. Successful retrieval occurred in 196 (89%) attempts. There were 7 patients who had open surgical IVC filter removal after failure of percutaneous retrieval. One patient had 2 filters and another had 3 filters. Except for 1 case with complications during the percutaneous retrieval procedure, the remaining patients all suffered from back or abdominal pain. All had significant filter strut penetration through the caval wall into adjacent structures. Postoperatively, all patients had relief of pain. There were no deaths and 1 patient had a minor ileus that spontaneously resolved. CONCLUSIONS: Patients who fail percutaneous IVC filter retrieval can expect low morbidity and prompt resolution of symptoms after open surgical removal via minilaparotomy.

Outcomes of Patients With Acute Type B (DeBakey III) Aortic Dissection: A 13-Year, Single-Center Experience.

BACKGROUND: Aortic dissection remains the most common aortic catastrophe. In the endovascular era, the management of acute type B aortic dissection (ATBAD) is undergoing dramatic changes. The aim of this study is to evaluate the long-term outcomes of patients with ATBAD who were treated at our center over a 13-year period. METHODS AND RESULTS: We reviewed patients with ATBAD between 2001 and 2014, analyzing variables based on status (complicated [c] versus uncomplicated [u]) and treatment modalities. We defined cATBAD as rupture, expansion of diameter on imaging during the admission, persistent pain, or clinical malperfusion leading to a deficit in cerebral, spinal, visceral, renal, or peripheral vascular territories at presentation or during initial hospitalization. Postoperative outcomes were defined as deficits not present before the intervention. Outcomes were compared between the groups by use of Kaplan-Meier and descriptive statistics. We treated 442 patients with ATBAD. Of those 442, 60.6% had uATBAD and were treated medically, and 39.4% had cATBAD, of whom 39.0% were treated medically to 30.0% with open repair, 21.3% with thoracic endovascular aortic repair, and 9.7% with other open peripheral procedures. Intervention-free survival at 1 and 5 years was 84.8% and 62.7% for uATBAD, 61.8% and 44.0% for cATBAD-medical, 69.2% and 47.2% for cATBAD-open, and 68.0% and 42.5% for cATBAD-thoracic endovascular aortic repair, respectively (P=0.001). Overall survival was significantly related primarily to complicated presentation. CONCLUSIONS: In our experience, early and late outcomes of ATBAD were dependent on the presence of complications, with cATBAD faring worse. Although uATBAD was associated with favorable early survival, late complications still occurred, mandating radiographic surveillance and open or endovascular interventions. Prospective trials are required to better determine the optimal therapy for uATBAD.

Prevention of perioperative vascular prosthetic infection with a novel triple antimicrobial-bonded arterial graft.

OBJECTIVE: Previously, we investigated a locally developed technique of bonding arterial grafts with three antimicrobials to protect against early (within 2 weeks) perioperative bacterial contamination encountered occasionally during aortic graft prosthetic reconstruction. Vascular graft infections are classified by their appearance time (early [<4 months] vs late [>4 months] after graft implantation), degree of incorporation into the surrounding vessel wall, connectivity to the postoperative wound, and extent of graft involvement. In the current phase of testing, we evaluated the ability of our novel triple antimicrobial-bonded graft to prevent infection in the first 8 weeks after implantation. METHODS: In nine Sinclair miniature pigs, we surgically implanted a 6-mm vascular Dacron patch graft in the infrarenal abdominal aorta. Five pigs received grafts chemically bonded with a 60-mg/mL solution of rifampin, minocycline, and chlorhexidine, and four pigs received unbonded grafts. Before implantation, the five bonded grafts and three of the unbonded grafts were immersed for 15 minutes in a 2-mL solution containing 1-2 × 107 colony-forming units (CFUs)/mL of Staphylococcus aureus (ATCC 29213); the fourth unbonded graft served as a control. RESULTS: At week 9, all of the grafts were explanted. All S aureus-inoculated bonded grafts (n = 5) showed no bacterial growth. The unbonded, uninoculated graft (n = 1) showed low-level bacterial growth (<1.2 × 103 CFUs); S cohnii spp urealyticus, but not S aureus, was isolated, which suggested accidental direct perioperative contamination. Two pigs that received S aureus-inoculated, unbonded grafts were euthanized because of severe S aureus infection (<6.56 × 108 CFUs per graft). Results of histopathologic analysis were concordant with the microbiologic findings. Most intergroup differences were observed in the inflammatory infiltrate in the aortic wall at the site of graft implantation. In all pigs that received bonded grafts, Gram staining showed no bacteria. CONCLUSIONS: Our triple-bonded aortic graft prevented perioperative aortic graft infection for at least 8 weeks in a porcine model. The synergistic antimicrobial activity of this graft was sufficient to prevent and/or eradicate infection during that period. Further studies are needed to assess the graft's ability to combat early-onset vascular graft infection for up to 4 months.

Utility of a tubularized extracellular matrix as an alternative conduit for arteriovenous fistula aneurysm repair.

OBJECTIVE: The treatment of segmental arteriovenous fistula aneurysms (AVFAs) remains a challenge in dialysis access preservation. We examined our experience with the use of tubularized extracellular matrix (ECM; CorMatrix, Roswell, Ga) for AVFA repair. METHODS: Between October 2013 and January 2015, we conducted a prospective study of CorMatrix ECM for AVFA repair. All patients underwent intraoperative fistulography. Patients with central venous stenosis or occlusion had simultaneous angioplasty and stenting as indicated. The aneurysm and overlying skin were then resected, and an ECM patch was fashioned into a tube for interposition repair. Patients with multiple AVFAs underwent staged repair. Cannulation of the repaired segments was allowed after 6 weeks. RESULTS: During the study period, 15 patients (40% male; mean age, 49.5 years) underwent 18 AVFA repairs using ECM (3 staged repairs). Six patients (40%) underwent simultaneous treatment of central vein lesions, whereas eight patients (53%) had associated skin erosion. Treated sites included radiocephalic (2), brachiobasilic (1), and brachiocephalic (15) AVFAs. All patients had hemodialysis at an alternative location on the same extremity without the need for catheter placement. Five patients underwent a follow-up ultrasound examination at a mean of 6 weeks. All studies demonstrated patency of the ECM segments without stenosis. At a mean follow-up time of 6.9 months, two thrombosis events were observed, both in patients with known refractory central venous stenosis treated with previous angioplasty (2) and stenting (1). Both patients required new access placement. No complications were attributable to ECM sites. CONCLUSIONS: ECM is an alternative conduit for salvage of an autologous AVFA. This technique may help avoid the use of prosthetic grafts and hemodialysis catheters. Patients with associated central venous stenosis are at risk of thrombosis.

Predictors of intervention and mortality in patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Patients with uncomplicated acute type B aortic dissection (uATBAD) have historically been managed with medical therapy. Recent studies suggest that high-risk patients with uATBAD may benefit from thoracic endovascular aortic repair. This study aims to determine the predictors of intervention and mortality in patients with uATBAD. METHODS: All patients admitted with uATBAD from 2000 to 2014 were reviewed, and those with computed tomographic angiography imaging were included. Multiplanar reconstruction was used to obtain double orthogonal oblique measurements. All measurements were obtained by a specialized cardiovascular radiologist (D.O.). The maximum aortic diameter, proximal descending thoracic aorta false lumen (FL) diameter, and area were recorded. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analysis using SAS v 9.4 (SAS Institute, Cary, NC). RESULTS: During the study period, 294 patients with uATBAD were admitted with 156 having admission computed tomographic angiography imaging available for analysis. The cohort had an average age of 60.6 years (±13.6 years); 60% were males. The average follow-up time was 3.7 years (interquartile range, 2.1-6.9). A stratified analysis demonstrated the most sensitive cutoff for mortality was aortic diameter >44 mm (P < .01), and it appeared to be a threshold effect with minimal additional information added by finer size stratification. FL diameter did not predict mortality in our series (P = .36). Intervention-free survival, alternatively, appeared to decrease over the range of diameters from 35 to 44 mm (P < .01). An FL diameter >22 mm was associated with decreased intervention-free survival (P < .04). Age >60 years on admission also demonstrated decreased survival compared with those ≤60 years of age (P < .01). Diameter >44 mm persisted as a risk factor for mortality (hazard ratio, 8.6; P < .01) after adjustment for diabetes (6.7; P < .01), age (1.06/y; P < .01), history of stroke (5.4; P < .01), connective tissue disorder (2.3; P < .01), and syncope on admission (9.5; P < .04). The 1-, 5-, and 10-year intervention rate for patients with admission aortic diameter >44 mm was 18.8%, 29.5%, and 50.3%, respectively, compared with 4.8%, 13.3%, and 13.3% in the ≤44 mm group (P < .01). CONCLUSIONS: Aortic diameter >44 mm is a predictor of mortality after adjustment for other significant risk factors. Age >60 years on admission is a predictor of mortality. An FL diameter >22 mm as well as those with maximum aortic diameter >44 mm on admission were associated with decreased intervention-free survival. Patients with these high-risk criteria may benefit from thoracic endovascular aortic repair. Further studies are needed to further define those patients at highest risk and, thus, most likely to benefit from early intervention.

Stenting of a Retropharyngeal Internal Carotid Artery.

A retropharyngeal course of the carotid artery is an uncommon variant. Recognition of this anatomic anomaly is important in avoiding severe hemorrhage with endotracheal intubation and oropharyngeal procedures and for planning carotid interventions. We present a rare case of stenting for an asymptomatic, high-grade stenosis in a retropharyngeal internal carotid artery.

Observation May Be Safe in Selected Cases of Blunt Traumatic Abdominal Aortic Injury.

BACKGROUND: Blunt traumatic abdominal aortic injury (BTAAI) is a rare lesion, often associated with extensive intraperitoneal injuries. Optimal management remains unclear, including the role of prosthetic aortic graft replacement with concomitant bowel injury and the management of small pseudoaneurysms. METHODS: We reviewed BTAAI cases occurring between 2000 and 2014. Thoracic and isolated iliac artery injuries were excluded. We included patient demographics, mechanism of injury, admission physiology, and reviewed available imaging to characterize aortic injury type and severity. RESULTS: BTAAI was noted in 16 of 8,751 (0.2%) blunt abdominal trauma patients admitted during the study period. Of these, 56% were males and the median age was 47 years (range, 5-80). Aortic repair was attempted in 7 patients, including 3 open prosthetic aortobi-iliac bypass grafts, 1 endovascular repair, and 2 primary repairs. One patient died before repair. The remaining patients were medically managed for their aortic injury, including 3 with pseudoaneurysm and 3 with large intimal flaps. There were 5 in-hospital deaths (31%) but only 1 attributed to aortic injury. Among patients surviving to discharge, there were no readmissions or delayed deaths. All nonoperative and surgically repaired patients seen in follow-up had stable aortic lesions. No patient with graft or endograft repair had evidence of graft infection on follow-up (median, 52 months; range, 21-121). CONCLUSIONS: BTAAI is a rare entity and is associated with high in-hospital mortality, primarily due to associated injuries. Observation of selected small pseudoaneurysms and intimal flaps appear safe. Survival after hospital discharge is excellent, and aortic-related complications are rare. The indications for repair and the role of revascularization with in situ prosthetic graft in the setting of concomitant bowel injuries are not well defined.

Need for Limb Revascularization in Patients with Acute Aortic Dissection is Associated with Mesenteric Ischemia.

BACKGROUND: Acute aortic dissection (AAD) can cause limb ischemia due to branch vessel occlusion. A minority of patients have persistent ischemia after central aortic repair and require peripheral arterial revascularization. We investigated whether the need for limb revascularization is associated with adverse outcomes. METHODS: We reviewed our cases of AAD from 2000 to 2014 and identified patients with malperfusion syndromes (coronary, cerebral, spinal, visceral, renal, or peripheral ischemia). Patients with DeBakey I/II (Stanford type A) dissection had urgent open repair of the ascending aorta. Patients with DeBakey III (Stanford type B) dissection were initiated on anti-impulse medical therapy and had either open aortic repair or thoracic endovascular aortic repair for malperfusion syndromes. Patients with persistent lower limb ischemia after aortic repair usually had either extra-anatomic bypass grafting or iliac stenting. Some DeBakey III patients had peripheral revascularization without central aortic repair. We performed univariate and multivariate analysis to determine the effects of need for limb revascularization and clinical outcomes. RESULTS: We treated 1,015 AAD patients (501 [49.4%] DeBakey I/II and 514 [50.6%] DeBakey III) with a mean age of 59.7 ± 14.5 years (67.5% males). Aortic repair was performed in all DeBakey I/II patients and in 103 (20.0%) DeBakey III patients. Overall 30-day mortality was 11.3%. Lower limb ischemia was present in 104 (10.3%) patients and was more common in DeBakey I/II compared with DeBakey III dissections (65.4% vs. 34.6%; odds ratio [OR] 2.1, confidence interval [CI] 1.4-3.2; P = 0.001). Among the 40 patients who required limb revascularization, there was no difference in need for revascularization between DeBakey I/II and III patients. Patients requiring limb revascularization were more likely to have mesenteric ischemia compared with the rest of the cohort in both DeBakey I/II (P = 0.037) and DeBakey III dissections (P < 0.001) with worse 10-year survival (21.9 % vs. 59.2%, P < 0.001). When adjusted for other malperfusion syndromes, patients with limb revascularization had similar long-term survival compared to uncomplicated dissection patients (P = 0.960). CONCLUSIONS: Patients requiring lower limb revascularization after treatment for AAD are more likely to have mesenteric ischemia and worse survival. The need for limb revascularization is a marker for more extensive dissection and should prompt evaluation for visceral malperfusion.

A Quarter Century of Organ Protection in Open Thoracoabdominal Repair.

INTRODUCTION: Thoracoabdominal aortic aneurysm (TAAA) remains a challenging problem. We sought to examine our experience with thoracic and thoracoabdominal aortic repairs over a 24-year period. METHODS: Patient information was collected in a prospective database and analyzed retrospectively. Univariate and multivariable analysis was performed. RESULTS: Between January 1991 and December 2014, we repaired 1896 descending thoracic (DTAA) or TAAA in 1795 patients. Mean age was 64.2 ±â€Š13.8, and 702 (37%) were women. Of 1896 operations, 646 (34.1%) were DTAA, 316 (16.7%) TAAA extent I, 310 (16.4%) TAAA extent II, 187 (9.9%) TAAA extent III, 348 (18.4%) TAAA extent IV, and 112 (5.9%) TAAA extent V. Adjunct [cerebrospinal fluid drainage (CSFD) + distal aortic perfusion (DAP)] was used in 78.4%. Mean preoperative glomerular filtration rate (GFR) was 75.1 ±â€Š14.9 mL/min/1.73 m. Renal dysfunction occurred in 461 (24.3%). Immediate neurodeficit (IND) occurred in 79 (4.2%) and delayed in 104 (5.5%). Of these, 47/104 (45%) recovered by discharge. Postoperative stroke was 95/1896 (5%). Early mortality was 302/1896 (15.9%). Mortality with GFR >95.3 was 28/457 (6.1%), and 131/432 (30.3%) was with GFR < 48.3 (P < 0.0001). Predictors of early mortality were age (P < 0.02), GFR (P < 0.0001), TAAA2 or 3 (P = 0.001), coronary artery disease (P = 0.001), and emergency (P < 0.0001). CONCLUSIONS: Open DTAA and TAAA repair can be performed with acceptable early and late outcomes. This study provides important early- and long-term data on open repair, allowing for better risk stratification of patients with DTAA and TAAA. It is the high-risk subgroup that can now be targeted for endovascular techniques.